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2 ObjectivesUnderstanding the stages and treatment of Adhesive CapsulitisUnderstanding of the mechanism underlying rotator cuff diseaseOutlining the stages of primary and secondary impingementFacilitating the development of evidence-based strategies to treat rotator cuff impingementMaking the appropriate referral for treatment

6 Adhesive Capsulitis Recognition-ClassificationAdhesive capsulitis- Nevaiser defined it as “the inflamed and fibrotic condition of the capsuloligamentous tissue.Codman described frozen shoulder as “a condition difficult to define, difficult to treat, and difficult to explain from the point of view of pathology.”Stiff and painful shoulder: painful condition with limited active and passive range of motion (ROM).

10 Etiology and Pathology cont.However, it is agreed that whether it is angiogenesis or synovitis that pain accompanies the change.Open and arthroscopic examination demonstrated significant capsuloligamentous complex (CLC) fibrosis and contractureAlso contracture of the rotator cuff interval (RCI) is prevalent

11 Rotator Interval (RCI)The RCI forms the triangular-shaped tissue between the anterior supraspinatus edge and upper subscapular border, and includes the superior glenohumeral ligament and the coracohumeral ligament.

15 Adhesive Capsulitis DiagnosisRule in if:Pt. age is between yearsPt. reports a gradual onset with progressive worsening of pain and stiffnessPain and stiffness limit sleeping, grooming, dressing, and reachingGlenohumeral passive ROM is limited in multiple directionsGlenohumeral ER or IR ROM decreases as arm is abducted from 45 to 90 degreesPassive motions into the patient’s end ROM reproduce the patient’s reported shoulder painJoint glides/accessory motions are restricted in all directions

16 Adhesive Capsulitis Diagnosis?Rule out if:Passive ROM is normalRadiographic evidence of glenohumeral arthritis is presentPassive ROM for ER and IR increases as you move from degrees and the reported pain is reproduced with palpatory provacation of the subscapularis myofasciaUpper-limb nerve tension testing reproduces the reported shoulder painShoulder pain is reproduced with palpatory provocation of the relevant peripheral nerve entrapment site

22 LLLDS is effective for improving Total End Range Time (TERT)Lentell reportedTime: minutesFrequency: 3-4x/dayDuration: 60min/dayLoad added to stretch is (.5% BW)

23 What do we need to know about connective tissue?In the absence of normal joint movement, the normal orientation of the connective tissue’s collagen fibers is lost.Long-lasting or plastic elongation is produced by exposing connective tissue.The effectiveness of a low-load long duration stretch (LLLDS) to promote long-lasting elongation of connective tissue is well documented.Studies also support that the temperature of the connective tissue at the time of the stretch can significantly influence the long-lasting change that is produced.Elevating the temperature of the tissue prior to the stretch and during the stretch produced greater changes and less tissue damage.

24 Joint mobilizations during Phase 3High-grade joint mobilizations are used to promote elongation of shortened fibrotic soft tissueMobilizations should be performed at or near physiologic end rangeImproved extensibility of the any portion of the CLC results in improved motion in all planesMulti-planar mobilization techniques utilize rotational stress with concomitant translation which loads the collagen in multiple planes

36 Primary ImpingementPrimary Impingement- compression of the RC tendons between the humeral head and overlying anterior third of the acromion, coracoacormial ligament, coracoid or AC joint.

37 Secondary ImpingementAttenuation of the static stabilizers of the GH joint, such as capsular ligaments and labrum, from the excessive demands incurred in throwing or overhead activities can lead to anterior instability

38 Internal ImpingementInternal impingement occurs when the shoulder is in a 90/90 position and the undersurface of the supra and infra tendons become compressed or pinched between the humeral head and the posterosuperior gleniod rim.

39 Rotator Cuff Tears Incidence increases with ageResearch shows that tears are present in 50% or more of the patient population greater than 60 years of ageTypically overuse injuries with compressive and shear forces

42 SummaryAdhesive capsulitis and RC tendinopathy are two of the most common diagnoses related to ongoing shoulder pain.Research and evidence based practice demonstrates positive functional outcomes when treated conservatively with PT.